Clinical profile of patients with cardiac amyloidosis in India

Limited data exists on patients with cardiac amyloidosis (CA) in India, due to underdiagnosis and late presentation. We present single centre data from 13 patients over a 4 year period with a median age of 65 years. A majority presented with symptomatic heart failure (69%) and eight patients had confirmed AL amyloidosis. At the end of the follow up period, 46% patients died, with 30% of the overall cohort dead within six months. Among the survivors, 71% continue to have NYHA grade III/IV symptoms. A suggested algorithm for earlier diagnosis in resource constrained settings is also presented.

Effect of environment and season on acute decompensated heart failure: Data from low-to middle-income country

Objectives: The environmental effect in heart failure (HF) patients is well established. However, the data is limited from low-to middle-income countries like India. This study determined the impact of environment on acute decompensated HF (ADHF) admissions and mortality in India. Methods: Retrospectively, the data of all HF patients admitted between April 2017 and March 2019 was accessed through electronic hospital records. Simultaneously, the environmental-related data was collected from the central pollution control board. Results: The study included 4561 patients of ADHF. The peak of monthly ADHF events (admission and mortality) was observed during the chilly month (January) while the lowest rates were observed in summer months (MayeJune). The most significant factor correlating inversely with the monthly ADHF admission (r ¼ 0.78, p ¼ 0.003) and mortality (r ¼ 0.65, p ¼ 0.004) was the maximum air temperature, and it was found to be the independent predictor for both ADHF mortality [t ¼ 2.78, b ¼ 0.84; 95%CI(-6.0 to 0.6), p ¼ 0.021] and admission [t ¼ 4.83, b ¼ 0.91; 95%CI(-19.8 to 6.9), p ¼ 0.001]. The above correlation was better seen in the elderly subset and male gender. Humidity and the air pollution attributes did not have a significant correlation with ADHF admission or mortality. Conclusion: In conclusion, even in low-to middle-income country like India, a periodic effect of season was demonstrated for ADHF mortality and admission, with a peak in ADHF events noted during winter months especially in the regions having extremes of seasons. Air pollution could not affect the ADHF outcome for which further studies are needed

Effect of Anti?Platelet Therapy on Peri?Operative Blood Loss in Patients Undergoing Off?Pump Coronary Artery Bypass Grafting

Purpose:The purpose of this study was to review the effect of the pre?operative use of clopidogrel and aspirin on peri?operative bleeding, blood product transfusion, and resource utilization after coronary artery bypass grafting (CABG). Materials and Methods: A total of 1200 patients who underwent off?pump CABG (OPCABG) between 2010 and 2012 were retrospectively studied. Patients were divided into three groups: group 1: discontinued aspirin and clopidogrel 6 days prior to surgery (n = 468), group 2: discontinued both drugs 3 to 5 days prior to surgery (n = 621), and group 3: discontinued both drugs 2 days prior to surgery (n = 111). The bleeding pattern and blood product transfusion were studied and compared between the groups. Patients having history of other drugs affecting the coagulation profile, other organ dysfunction, on?pump CABG, and the combined procedure were excluded from the study. Results: Group 2 patients had a higher rate of bleeding and a reduced mean value of hemoglobin (Hb) as compared to other groups. The same results were seen in blood and blood product transfusion. Patients of group 2 and group 3 were associated with higher blood loss in terms of drainage at 12 and 24 hours. Post?operatively, this was statistically significant. Re?exploration was statisitically significant in group 3 patients (9.01%) than in group 2 (2.58%) and group 1 (1.07%) patients. Conclusion: The pre?operative use of clopidogrel and aspirin in patients undergoing OPCABG showed limited clinical benefits; however, its use significantly increased the risk of bleeding and blood transfusion, thus increasing morbidity and resource utilization. Hence, clopidogrel and aspirin should be stopped at least 6 days prior to surgery.

Vascular Access Complications in Patients Undergoing Veno-Arterial ECMO and Their Impact on Survival in Patients With Refractory Cardiogenic Shock: A Retrospective 8-Year Study

Introduction:Veno-arterial extracorporeal membrane oxygenation (ECMO) is well-recognized treatment modality for patients with refractory cardiogenic shock. Uncomplicated cannulation is a prerequisite and basis for achieving a successful outcome in ECMO. Vascular access is obtained either by surgical cut-down. Common vascular access complications are bleeding and limb ischemia. Objective: To evaluate cannulation technique, the incidence of vascular complications, and their impact on the outcome. Methods: A retrospective data analysis conducted on 95 patients receiving ECMO from 2013 to 2020 was done. The patients were divided into two groups: no vascular access complications (non-VAC group) and vascular access complications (VAC group). The groups were compared related to the hospital and ICU stays and blood transfusion. Results: The patients in both groups were demographically and clinically comparable. The Non-VAC group had 75 patients, whereas the VAC group had a total of 20 patients. The main complication observed in the VAC group was bleeding from the cannulation site which required more blood transfusion than the non-VAC group (6.8 ± 1.02 vs 4.2 ± 1.26). Limb ischemia was another complication seen in the VAC group (4.2%, n = 4). Two patients had delayed bleeding after decannulation. The overall average length of stay in the hospital was statistically similar in both the groups (22 days in the VAC group vs 18 days in the non-VAC group), but the average ICU stay was more in the VAC group compared to the non-VAC group (18 days vs 12.06 days). Conclusion: Bleeding and limb ischemia are the important vascular access site complications, which increase blood transfusion requirements, ICU stay, and overall hospital stay.

Analysis of Anticoagulation Therapy Related Complications in Patients With Prosthetic Valves: Our Experience

Purpose:The aim of this study is to analyze anticoagulation?related complications in patients following mechanical valve replacement and factors influencing the outcome. Materials and Methods: A total of 250 patients were analyzed during OPD follow?up for anticoagulation?related complications and various factors influencing outcome. Patients received prosthetic valve at mitral and/or aortic or both. Results: Out of 250 patients, 48% were male and 52% were female. The mean age was 41.9 ± 14.4. A total of 139 had mitral valve replacement (MVR), 70 had aortic valve replacement (AVR), 40 had double valve replacement (DVR), and 1 patient had triple valve replacement. Valves implanted were mechanical bileaflet valve. The mean international normalization ratio (INR) in the study was 2.4 ± 0.56. A total of 49 events occurred during follow?up, of which 4.5% per patient years were anticoagulation?related hemorrhagic events and 4.8% per patient years were thromboembolic events. Among thromboembolic events, valve thrombosis occurred in 10 patients and cerebrovascular accidents occurred in 11 patients. Mean INR for thromboembolic events was 1.46 ± 0.25 and anticoagulation?related hemorrhagic events was 4.4 ± 1.03. Mortality rate was 1.6% in AVR, 4% in MVR, and 0.4% in DVR? groups; about 34% of patients needed dose modification of Acenocoumarol and reason for derangement of INR was associated with infectious process and poor compliance; 85% of cases showed good compliance for daily anticoagulation therapy. Conclusion: Anticoagulation for mechanical valve replacement can be managed with INR range of 2.0 to 2.5 in MVR and 1.5 to 2.0 in AVR with acceptable hemorrhagic and thromboembolic events. We must educate and counsel the patients during follow?up for better compliance to optimal anticoagulation.

Evaluation of intracoronary blood from obstructive vessel in patients of ST-elevation myocardial infarction undergoing PPCI

Objective Information available on acid–base imbalance in ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention is limited and no data were present on intracoronary blood analysis, extracted from obstructed artery. Methods This was a prospective study conducted over 12 months in which STEMI patients presenting in emergency and undergoing primary percutaneous coronary intervention were included. Blood gas analysis of intracoronary arterial blood from obstructed vessel and peripheral arterial blood was performed. Patients in whom adequate intracoronary sample could not be obtained were excluded. Intracoronary and peripheral arterial blood gas measurements were correlated and relationship of intracoronary parameters were compared with clinical parameters, investigational markers and short-term outcome. Results The mean age of study population was 54.8 years and average symptom onset to door time was 162 min. On comparing intracoronary blood with peripheral blood arterial obtained, pH (95% confidence interval [CI] −0.01 to 0.02;p = 0.44), lactate (95% CI 0.03–0.1;p = 0.28), bicarbonate (95% CI 0.6–1.5;p = 0.64), pCO2 (95% CI 1.1–2.4;p = 0.79) and pO2 (95% CI 3.2–47.5; p = 0.06) were all found to be statistically insignificant. Intracoronary hyperlactatemia was present in patients presenting with higher symptom onset to door time (p = 0.025). Systolic blood pressure (SBP) (p = 0.03) was also significantly lower in patients who had high intracoronary lactate levels. Conclusion The evaluation of intracoronary blood provides no additional information regarding the prognosis and short-term (30-day) outcome of the patients when compared with peripheral blood. However, there was a significant intracoronary hyperlactatemia in patients presenting late after symptom onset. SBP was also significantly less in patients with high intracoronary lactate, which signifies that predominant cause of hyperlactatemia was systemic hypoperfusion rather than local increase in lactate levels.

Unusual case of intraoperative acute cor pulmonale during spine surgery

Perioperative complications of prolonged surgery and prone positioning are well known. Changing the position from prone to supine in an anesthetized patient can result in aspiration and airway obstruction. The drop-in oxygen saturation and hemodynamic changes are warning signs and can cause acute cardiac decompensation leading to diagnostic dilemma. We present a case where the patient had these changes after changing the position after spine surgery in prone position. A quick response from the treating anesthesiologist and active involvement of cardiologist helped in reaching the diagnosis and successful management of aspiration pneumonitis in this patient. We conclude that a quick response in investigations and multimodality approach helps in the management of such perioperative complications.

Factors affecting seasonal changes in blood pressure in North India: A population based four-seasons study

Objective There are no community based, longitudinal, intra individual epidemiological studies on effect of weather and season on blood pressure (BP). We evaluated the effect of season and temperature on prevalence and epidemiology of BP in tropical climate. Methods and results It was a longitudinal cross sectional survey of rural and urban subjects in their native surroundings. BP was measured in four different seasons in same subjects. A total of 978 subjects (452 rural and 521 urban) were included in the current analysis. Demographic characteristics such as age, gender, education, occupational based physical activity and body mass index (BMI) were recorded. Mean BP, both systolic and diastolic were significantly higher in winter season as compared to summer season. Mean difference between winter and summer was 9.01 (95% CI: 7.74–10.28, p < 0.001) in systolic BP and 5.61 (95% CI: 4.75–6.47, p < 0.001) in diastolic BP. This increase in BP was more marked in rural areas and elderly subjects. Prevalence of hypertension was significantly higher during winter (23.72%) than in summer (10.12%). Conclusion BP increases significantly during winter season as compared to summer season. Increase is more marked in rural areas and elderly subjects. Seasonal variation in BP should be taken into account while looking at prevalence of hypertension in epidemiological studies.

Maternal Heart Disease and Pregnancy Outcomes.

This study was conducted to assess the presence of various types of cardiac lesions in pregnant females admitted to a tertiary care hospital of Punjab. 97 women having pregnancy and heart disease were assessed for the various etiologies, cardiac lesions, maternal and perinatal outcomes. Rheumatic heart disease (RHD) with isolated mitral stenosis was the commonest acquired lesion while mitral valve prolapse was the predominant lesion among the congenital heart disease. In the miscellaneous group, cardiomyopathy was the leading cause. Multiple cardiac lesions were diagnosed in 36 women. Majority delivered by caesarean section and some had spontaneous vaginal delivery while few required induction of labour. 19 women had cardiac complications. There were three maternal deaths.This study concluded that rheumatic heart disease in pregnancy is still predominant though acquired cardiac lesions are rising. A careful observation and management during pregnancy can improve the maternal & fetal outcomes.

Pulmonary Embolism in cases of Pulmonary Tuberculosis: A unique entity.

Pulmonary tuberculosis is very prevalent in developing countries but its thrombogenic potential is a new entity. There are reports stating the relation of Deep Vein Thrombosis (DVT) with severe forms of tuberculosis but no literature is available for correlation of pulmonary tuberculosis and pulmonary embolism. We are presenting series of five patients with different forms of tuberculosis presenting with pulmonary embolism having no risk factor for hypercoagulability. Also, serum protein C, protein S, antithrombin and factor V levels were normal in all. We are highlighting an unreported phenomenon so that high suspicion, adequate prophylaxis and prompt management of pulmonary embolism can play a vital role in the survival of this subset of patients.

Milrinone infusion: a therapeutic option in coronary vasospasm after primary percutaneous transluminal coronary angioplasty.

A 42-year-old male presented to the emergency department with acute chest pain. The electrocardiogram revealed inferior wall myocardial infarction. Emergency coronary angiography revealed total occlusion of the distal right coronary artery with thrombus. Patient was taken up for primary percutaneous coronary angioplasty with stenting of distal right coronary artery. Six hours following the procedure, the patient developed re-elevation of ST-segment in inferior leads of electrocardiogram and subsequent haemodynamic instability. Repeat coronary angiography revealed patent stent and coronary artery spasm in proximal part, which was relieved by intracoronary injection of nitroglycerine. After an hour, the patient re-developed symptoms of chest pain along with bradycardia, hypotension and ST segment elevation. Intravenous infusion of nitroglycerine did not improve the condition but produced persistent hypotension. Infusion of milrinone was then started. Over time, normalisation of electrocardiogram occurred. The patient was discharged in stable condition. This case suggests that milrinone may be effective in alleviating coronary artery spasm when the use of other agents fails.

Clinical and angiographic profile of patients presenting with first acute myocardial infarction in a tertiary care center in northern India.

OBJECTIVE: Acute myocardial infarction (AMI) is one of the presentation of coronary artery disease (CAD) and is thought to occur in younger age group in this region. The objective of this study was to evaluate clinical, biochemical and angiographic profile of patients with first acute myocardial infarction. METHODS: Eight hundred and forty-six consecutive patients who underwent coronary angiography within 4 weeks of MI were included. RESULTS: Males (n = 705, 83.3%) outnumbered females (n = 141, 16.7%) in each age group. Mean age of presentation was lower in females (58.25 +/- 9.69: 55.74 +/- 10.63). Three hundred and forty-two (40.8%) patients were thrombolyzed. Most common type of MI was anterior wall MI (n = 485, 57.32%). Three hundred and forty (40.4%) were diabetic with females outnumbering males proportionately (females = 63, 44.68%: males = 277, 39.29%). More females were hypertensive (females = 81, 57.45%: males = 306, 43.40%). Prevalence of smoking was quite low (n = 140, 16.50%) and mean age of smokers was less by 7 years than non-smokers. One hundred and forty-two (16.7%) were obese with mean age of presentation less by 7 years than non-obese. Single vessel disease (SVD) was more prevalent (361/846; 42.67%) and was more common in younger, non-diabetics and smokers. Diabetics were more likely to have triple vessel disease (TVD) (n = 112, 32.95%). CONCLUSIONS: The study reveals that age of first AMI was comparable to that in western world. Females tend to be more hypertensive and diabetics. Younger, non-diabetics and smokers tend to have single-vessel disease. Diabetics and older population were more likely to have diffuse disease (TVD).

Gastrointestinal bleed after leeching in a patient on aspirin therapy.

Leeches ( Hirudo medicinalis ) have been used in health care for their property of bloodletting. Bleed occurring from the site of leech attachment has been well documented. We report a 50-year-old man who was on aspirin therapy for coronary artery disease, and presented with GI bleed after leech treatment for his knee pain.

Syncope in a middle aged male due to acute rheumatic fever.

Rheumatic fever is a multi system disease which occurs following infection with group A beta hemolytic streptococcus. It is commonest in the age group of 5-15 years but can occur in adults also. First degree atrioventricular block is a common manifestation of acute rheumatic fever and is included in the Jones criteria but Wenckebacks phenomena and complete heart block are relatively rare manifestations of rheumatic fever. Syncope occurring in acute rheumatic fever is also infrequently reported. We report the case of a 38-year-old male with rheumatic carditis who had advanced atrioventricular block which resulted in syncope and required a temporary pacemaker insertion.

Prevalence of sustained hypertension and obesity in urban and rural school going children in Ludhiana.

BACKGROUND: Increasing trend of hypertension is a worldwide phenomenon. The data on sustained hypertension in school going children is scanty in India. The present study was conducted to evaluate the prevalence of sustained hypertension and obesity in apparently healthy school children in rural and urban areas of Ludhiana using standard criteria. METHODS AND RESULTS: A total of 2467 apparently healthy adolescent school children aged between 11-17 years from urban area and 859 students from rural area were taken as subjects. Out of total 3326 students, 189 were found to have sustained hypertension; in urban areas prevalence of sustained hypertension was 6.69% (n=165) and in rural area it was 2.56% (n=24). Males outnumbered females in both rural and urban areas. The mean systolic and diastolic blood pressure of hypertensive population in both urban and rural population was significantly higher than systolic and diastolic blood pressure in their normotensive counterparts (urban normotensive systolic blood pressure:115.48+/-22.74 mmHg, urban hypertensive systolic blood pressure: 137.59+/-11.91 mmHg, rural normotensive systolic blood pressure: 106.31+/-19.86 mmHg, rural hypertensive systolic blood pressure: 131.63+/-10.13 mmHg, urban normotensive diastolic blood pressure: 74.18+/-17.41 mmHg, urban hypertensive diastolic blood pressure: 84.58+/-8.14 mmHg, rural normotensive diastolic blood pressure: 68.84+/-16.96 mmHg, rural hypertensive diastolic blood pressure: 79.15+/-7.41 mmHg). Overweight populationwas significantly higher in urban area. There were 287 (11.63%) overweight students and 58 (2.35%) were obese. In rural population overweight and obese students were 44 (4.7%) and 34 (3.63%) respectively. There was significant increase in prevalence of hypertension in both rural and urban population with increased body mass index in urban students; those with normal body mass index had prevalence of hypertension of 4.52% (n=96), in overweight it was 15.33% (n=44) and in obese it was 43.10% (n=25). In rural area, the overweight students showed prevalence of sustained hypertension in 6.82% (n=3) and in obese group it was 61.76% (n=21). None of the student with normal body mass index in rural area was found to be hypertensive. The mean body mass index of hypertensive population in both rural and urban areas was significantly higher than respective normotensive population (mean body mass index in urban normotensive group: 20.34+/-3.72 kg/m2, hypertensive group: 24.91+/-4.92 kg/m2; mean body mass index in rural normotensive group: 18.41+/-3.41 kg/m2, hypertensive group: 21.37+/-3.71 kg/m2, p<0.01). CONCLUSIONS: Prevalence of sustained hypertension is on the rise in urban area even in younger age groups. Blood pressure is frequently elevated in obese children as compared to lean subjects. This is possibly related to their sedentary lifestyle, altered eating habits, increased fat content of diet and decreased physical activities.